Tendinosis Tendinopathies • Defined as non-inflammatory intratendinous collagen degeneration Bernard F. Hearon, M.D. Clinical Assistant Professor, Department of Surgery • Angiofibroblastic hyperplasia - University of Kansas School of Medicine - Wichita hypertrophic fibroblasts, vascular April 23, 2019 hyperplasia, disorganized collagen • Areas of focal necrosis, calcification • No acute inflammatory cells

Elbow Tendinopathies

Distal Potential Mechanisms of Rupture: Arterial Supply, Mechanical Impingement. Seiler Tendinosis vs Tendinitis et al., JSES 1995; 4: 149-56. • “Tendinosis” implies an intrinsic degenerative • Proximal one-third supplied by condition, determines therapeutic goals, sets • Distal one-third from posterior interosseous reasonable outcome expectations recurrent artery • “Tendinitis” implies an inflammatory condition, • 2-cm middle-third is a hypovascular zone where is misleading, allows misguided treatment & blood supply is from paratenon unreasonable expectations • Radioulnar space for tendon is 48% less in pronation than in supination • Basic Science study (Emory University) Elbow Tendinopathies Elbow Tendinopathies Read File Distal Biceps Ruptures Bilateral ruptures of the distal biceps brachii tendon Epidemiology Schneider et al., JSES 2009; 18: 804-07. • 25 pts, non-simultaneous bilateral biceps ruptures • Male mesomorphs (rare in females) • All pts male, average age 50 (range 28 to 76) Age range 30-60 years (mean age 47) • • Mean time between ruptures 2.7 yrs (0.5 to 6.3) • Dominant extremity (86%) • Pts found to have higher rate of nicotine (50%) • Incidence 1.2 ruptures / 100K / year (rare) and anabolic steroid use (20%) • Smokers 7.5 times greater risk • Therapeutic Level IV study (Fondren, Houston)

Elbow Tendinopathies Elbow Tendinopathies Read File

Distal biceps tendon insertion: An anatomic study Distal Biceps Anatomy Hutchinson et al., JSES 2008; 17: 342-46. • 20 cadavers dissected to define biceps footprint • Short head and long head • Insertion at posteroulnar to middle aspect of the • Musculocutaneous innervation in all specimens • Elbow flexor, supinator • Shape of insertion is semilunar or oval • Radial tuberosity insertion • Reinsertion should be aimed at the posteroulnar • Bicipital (lacertus fibrosis) aspect of the radial tuberosity • Basic Science study (UTHSC - San Antonio)

Elbow Tendinopathies Elbow Tendinopathies Read File Distal Biceps Tendon Anatomy: A Bicipital Aponeurosis Cadaveric Study (Lacertus Fibrosis) Eames et al., JBJS 2007; 89A: 1044-49. Arises from short head biceps • In 10/17 cadavers, long & short heads had • distinct insertions on radial tuberosity • Envelops volar forearm muscles • Short head inserted distally, better flexor • Statically, stabilizes the biceps • Long head inserted proximally, better supinator • Dynamically, flexor-pronator contraction pulls biceps medially • Bicipital aponeurosis may be stabilizer • Should lacertus be preserved or • Basic Science study (Australia) released during biceps repair?

Elbow Tendinopathies Read File Elbow Tendinopathies

Clinical History Clinical Exam

Absence palpable tendon (hook test) • Sudden forced extension on flexed elbow • Bicipital crease interval (bicipital crease ratio) • Eccentric contraction of the biceps • Weakness on resisted forearm supination • Tearing sensation anterior elbow, audible pop • Biceps squeeze test • Abnormal biceps contour, reverse “Popeye” • Passive forearm pronation test • Weakness elbow flexion, forearm supination • • Bicipital aponeurosis flex test

Elbow Tendinopathies Elbow Tendinopathies Diagnostics Best MRI for Distal Biceps FABS Technique • Radiographs may show spurs, avulsion fracture • Ultrasound may confirm Flexed elbow complete rupture Abducted • MRI most helpful for partial distal biceps tear Supinated forearm

Elbow Tendinopathies Elbow Tendinopathies

Nonoperative Treatment of Distal Biceps Tendon Ruptures Freeman et al., JBJS 2009; 91-A: 2329-34. JSES 2019 - Therapeutic Level IV - Univ Pittsburgh • 20 cases (18 pts, 16 males), 50 yrs (range 35-74) • 14 pts rx nonoperatively matched to 18 uninjured • 7 dominant , 9 nondominant arm, 2 both • Assessed w/DASH, SANE, torque dynamometer • Mean supination strength 74% +/- 33%, mean • flexion strength 88% +/- 16% • Outcomes - clinically meaningful impairment • Overall satisfactory outcomes, one unsatisfactory • Supination power decreased by 47% • Therapeutic Level IV study (Erie, PA) • Useful in preoperative patient counseling

Elbow Tendinopathies Read File Elbow Tendinopathies Read File Classic Two-Incision Technique Evolution of Single Anterior Morrey, 1985 Incision Repair

Anterior incision, deliver tendon, whip stitch Date Author Technique • 1996 Lintner Suture anchors • Advance large clamp between radius & ulna 2000 Bain Endobutton • Posterior approach between EDC and ECU 2005 Mazzocca Endobutton, screw • Expose and prepare radial tuberosity, deliver 2008 Mazzocca Cortical button, screw sutures through drill holes and tie 2011 Siebenlist Two IM cortical buttons 2013 Tanner Direct suture repair

Elbow Tendinopathies Elbow Tendinopathies

Does immediate elbow mobilization after Cortical Button distal biceps tendon repair carry risk? Tension-Slide Method Smith et al., JSES 2016; 25: 810-15. • 22 distal biceps repairs w/cortical button technique Dx complete tear is clinical • • Pts encouraged to begin early elbow ROM on DOS MRI unnecessary • • All male pts, mean age 40.6 yrs, mean F/U 16.6 mo Single incision, cortical button w/o screw • • No pt complaints, wound dehiscence, repair failure Tie down with knot pusher • • 33% experienced transient neurapraxia • Therapeutic Level IV study (UK)

Elbow Tendinopathies Elbow Tendinopathies Read File Single vs Double-Incision Technique - Distal Biceps Tendon Repair Grewal et al., JBJS 2012; 94-A: 1166-74. • JSES 2017 - Level III Case-Control Rx - Canada • Single incision, two suture anchors (n = 47) • 16 delayed repairs (> 21d) matched w/acutes (1:3) • Double incision, transosseous drill holes (n = 44) • Time to surgery - 37 ± 12 days vs 10 ± 6 days • Elbow flexion strength 10% better w/two incisions • Complications - 63% (paresthesias) vs 29% (2 re-tears) • LABC neurapraxia 40% pts w/one incision • No difference in outcomes - DASH, PREE, ASES • Four tendon re-ruptures due to noncompliance • Therapeutic Level I study (Canada)

Elbow Tendinopathies Read File Elbow Tendinopathies Read File

Distal Biceps Partial Tears Distal Biceps Anatomy • Anterior elbow pain radiating to biceps often after injury event (lifting, forced extension) Tendon may be bifurcated (13%) • Tender distal biceps, weak resisted supination • • MRI often diagnostic but may be equivocal • Partial tear may be short head only • Nonsurgical rx including PT does not help • Short head tear may extend to long head • Surgical options are in situ repair vs take-down and re-attachment

Elbow Tendinopathies Elbow Tendinopathies Surgical Treatment of Partial Distal Biceps Tendon Ruptures Frazier et al., JHS 2010; 35-A: 1111-14. • JSES 2018 - Level IV Rx - Thomas Jefferson Univ • Retrospective review 17 pts w/partial tears • 74 pts w/partial tears, 13 immediate surgery • 14/17 failed nonoperative treatment • Nonoperative - 34 of 61 (56%) had late surgery • One re-rupture, two LABC neurapraxia • Satisfaction same for early or late operation • Elbow flexion 10% stronger, supination 10% • High-demand occupations did better w/surgery weaker than contralateral side • MRI-dx tear > 50% predicted need for surgery • Therapeutic Level IV study (Univ Pittsburgh)

Elbow Tendinopathies Read File Tendinopathies Reading List

Partial Tears of the Distal Biceps Tendon: Distal biceps tendon tears in women A Systematic Review of Surgical Outcomes Jockel et al., JSES 2010; 19: 645-50. Behun et al., JHS 2016; 41-A: e175-e189. • 15 cases (13 pts), mean age 63 yrs (range 48-79) • Meta-analysis 19 studies, 86 partial tears repaired • 7 single injury, 8 insidious onset, 6 cystic mass • 65 pts had failed trial non-surgical treatment • 14 partial tears, all did well with surgical repair • Surgical repair yielded 94% satisfactory outcome • Distal biceps tears rarely occur in women • LABC paresthesia most common (17%) complication • Age is older than men, no trauma, associated • Therapeutic Level IV study (Western Michigan Univ) with cyst, mostly partial tears • Therapeutic Level IV study (Tufts University)

Elbow Tendinopathies Read File Elbow Tendinopathies Read File Surgical Complications Chronic Tears • LABC neurapraxia • Primary repair in extreme flexion • PIN palsy • Reconstruction with Achilles tendon allograft • Heterotopic ossification • Lacertus fibrosis local autograft • Radioulnar synostosis • Tenodesis to brachialis • Tendon re-rupture • CRPS / RSD • Wound infection

Elbow Tendinopathies Elbow Tendinopathies

Drilling Angle & PIN Safety • JSES 2018 - Level III Treatment - Carolina Med Ctr • Position full supination • CPT code 24342, January 2005 - April 2017 • Drill perpendicular to long axis of radius • Single incision - 652 cases, 2-incision - 318 cases • Aim 0 to 30 degrees ulnarly to improve margin of safety • 7.5% major complication, 4.5% re-operation • Basic Science study (Naval Med Ctr, San Diego) • Single incision - increased LABC or SRN neuritis • Two-incision - increased radioulnar synostosis

Elbow Tendinopathies Elbow Tendinopathies Read File Review of 150 Acute Ruptures Diagnosis Mirzayan et al., 2014 ASES Meeting Eccentric load, resisted elbow extension • Average age 49 years (range 15 to 79) • Weight lifters, offensive linemen in football • Males 93%, dominant side 70% • • Exam - pain & weakness w/resisted extension, • Injury mechanism - fall 51%, weight lifting 20% palpable tendon defect, positive squeeze test • Bony avulsion on lateral radiograph 58% • XR - bony avulsion or olecranon fracture • Complete rupture 77%, at bony insertion 97% • MRI - for confirmation of partial tears and to • Smokers 7%, anabolic steroid use 3% assess degree of injury

Elbow Tendinopathies Elbow Tendinopathies

Triceps Tendon Repair Bennett & Mehlhoff, JHS 2015; 40: 1677-83. Treatment Methods • Most common 30-50 yrs, majority male 3-to-2 • Partial tears < 50% (myotendinous junction • Predisposed by olecranon bursitis, spurring, or intratendinous) - extension splinting steroid injection, anabolic steroids Acute complete tears < 3 wks - anatomic Injury mechanism - fall, weight-lifting, pushing • • repair by transosseous suture or anchors • PE - weakness/inability to extend against gravity • Chronic tears w/retraction - reconstruction • XR - proximally retracted olecranon fragment w/tendon autograft or allograft • MRI - confirms dx, degree of injury/retraction

Tendinopathies Reading List Elbow Tendinopathies Snapping Triceps Syndrome • syndrome ± ulnar n subluxation JSES 2017 - Level III Rx - USA multiple centers • • Male laborers, athletes, weight-lifters • 56 male pts 2006-2013, minimum 2-yr follow-up • May present with double snap w/elbow flexion • 59% transosseous repair, 41% suture anchors - ulnar nerve subluxes at 70°-90° flexion • Outcome measures were MEPS, DASH - medial head triceps dislocates at 115° flexion • No significant clinical differences • Exam - triceps tension accentuates snapping • Two triceps repair failures in each group • Dx - MRI, ultrasound (best), EMG/NCS

Elbow Tendinopathies Read File Elbow Tendinopathies

Snapping Medial Triceps - Potential Causes Snapping Medial Triceps Treatment Options • Prominent or hypertrophic medial head • Anomalous 4th head of triceps • Activity modification, flexion block orthosis • Hypoplasia medial epicondyle • Treat ulnar nerve by anterior transposition • Cubitus varus from displaced supracondylar fx • Treat medial head by excision or centralization • Muscle dynamics - differential head activation

Elbow Tendinopathies Elbow Tendinopathies Lateral Epicondylosis Epidemiology Anatomy & Histology • Affects 1-3% adults per year Age range 30-50 years • ECRB most commonly affected • Men & women equally affected • EDC involved 35-50% patients • More common on dominant side • No evidence of acute inflammation • Risk factors include repetitive Angiofibroblastic tendinosis (Nirschl, 1979) • • lifting, manual labor

Elbow Tendinopathies Elbow Tendinopathies

Clinical Diagnosis • Insidious onset or lateral elbow trauma • JHS 2016 - Level I Diagnostic - Harvard, Univ Texas Wrist extension activity is provocative • • Theory - ECRB changes on MRI increase with age PE - tenderness at CEO, positive resisted • • 369 of 3374 MRI reports (11%) showed ECRB signal wrist extension change w/o clinical evidence of tennis elbow • XRs - may show CEO calcification 7%, • Prevalence increased from 5.7% (18 - 30 yrs) to 16% in but rarely alter management patients 71 yrs or older • MRI - may quantify tendon involvement • ECRB enthesopathy is highly prevalent, self-limited

Elbow Tendinopathies Elbow Tendinopathies Read File • Activity modification • NSAIDs 2018 ASSH Survey • Orthoses Lateral Epicondylitis Nonsurgical • Stretching, ASTYM Treatment • Eccentric strengthening • How many pts/yr do you manage? - 60 Options • Iontophoresis • How many pts/yr do you operate? - 9 • Steroid injection • Have you ever had lateral epicondylitis? - 58% • PRP injection • Have you had corticosteroid injection? - 11% Botox injection • • Have you had surgery for LE? - 0.43% • Autologous blood injection Elbow Tendinopathies • Extracorporeal shock wave Elbow Tendinopathies

2018 ASSH Survey 2018 ASSH Survey - Steroid Injections for Lateral Epicondylitis Treatment for Lateral Epicondylitis • Do you offer steroid injections? Yes - 73% • Most effective nonoperative treatment? • Why? 90% - for immediate pain relief - Education for activity modification - 73% • When? 52% - for extreme pain only - Muscle stretching - 46% - Eccentric strengthening - 33% • What? 50% - betamethasone & lidocaine • When do you consider surgery? • Technique? 45% - barbotage, vary direction - < 3 mo - 0.45% - 9-12 mo - 19% Interval? 46% - 3-month intervals - 3-6 mo - 10% - > 12 mo - 35% • - 6-9 mo - 26% - Never - 9% • Maximum? 33% - 3 injections; 33% - only 2 Elbow Tendinopathies Elbow Tendinopathies • Acupuncture • Continuous ultrasound Nonsurgical • Extracorporeal shock wave • Laser therapy Treatments • Glycosaminoglycan injection in Meta- • Autologous blood injection • AJSM 2018 - Level I Meta-analysis - Harvard Univ • Botulinum toxin injection • 36 studies, 11 conservative treatments, 2746 patients analysis • Corticosteroid injection • Most pts had pain relief w/placebo within 4 weeks • Iontophoretic administration Rx - small pain relief, increasing odds of adverse effects • • Protein-rich plasma injection Elbow Tendinopathies Read File Elbow Tendinopathies • Pulsed electromagnetic field

Arthroscopic classification and treatment of Tennis Elbow: The Surgical Treatment of lateral epicondylitis: two-year clinical results Lateral Epicondylitis Baker et al., JSES 2000; 9: 475-82. Nirschl et al., JBJS 1979; 61A: 832-39. • 42 arthroscopic releases on 40 pts, avg age 43 yrs • 1213 cases of lateral epicondylitis (1971-77) • 15 type I (intact capsule), 15 type II (linear tear), • 88 in 82 pts had open ECRB debridement 12 type III (complete capsular tear) Results - excellent 66, good 9, fair 11, failed 2 • 69% had associated pathology including synovitis, • bone spurs, loose bodies, arthritis 98% improved, 85% returned to full activity • • ECRB debrided, lateral epicondyle decorticated Therapeutic Level IV study (Georgetown Univ) • • 37 of 39 elbows were “better” or “much better” • Therapeutic Level IV study (Hughston Clinic, GA) Elbow Tendinopathies Read File Elbow Tendinopathies Read File Arthroscopic vs Open Lateral Release for The Nirschl procedure versus arthroscopic Lateral Epicondylitis ECRB débridement for lateral epicondylitis McDonald et al., 2014 ASES Meeting Kwon et al., JSES 2017; 26: 118-24. 29 elbows, 26 pts (Nirschl), 30 elbows, 29 pts (scope) • Prospective, randomized, controlled trial • F/U mean 2.5 yrs, measured DASH, VAS, grip strength • Open - 15 women, 19 men (avg age 47.1 yrs) • Both techniques effective, comparable outcomes • Arthroscopic - 13 women, 21 men (avg age 45.0 yrs) • Slightly better pain relief in open group w/hard work • No differences in outcome at 12 months postop • Therapeutic Level III study (South Korea) • Therapeutic Level I study (Canada) •

Elbow Tendinopathies Elbow Tendinopathies Read File

• JHS 2019 - Level I Therapeutic - Belgium • AJSM 2018 - RCT Level II Therapeutic - Australia • Theory - adding PIN release would improve outcome • 26 pts recruited for ECRB debridement vs placebo • 54 pts w/lateral epicondylosis, w/o radial symptoms surgery (sham debridement) • Half had PIN decompression w/CEO release • Goal was 40 pts each group; suspended after 6 years • Outcomes measures - QuickDASH, MEPS • No significant differences in pain, function at 2.5 yrs • No difference in CEO release outcome w/PIN release • No benefit excising degenerative portion ECRB

Elbow Tendinopathies Read File Elbow Tendinopathies Read File Effect of corticosteroid injection, physiotherapy Treatment Protocol or both in patients with lateral epicondylalgia • Activity modification, counterforce strap, Coombes et al., JAMA 2013; 309(5): 461-9. short-arm splint (night), encourage patience • Randomized, placebo-controlled study 165 pts OT - stretching, strengthening, ASTYM • • Four groups - steroid injection, placebo injection, • Aggressive needling / trephination w/lidocaine steroid & PT, placebo & PT • If no better after one year, open CEO release, • Steroid injection vs placebo worse at one year partial epicondylectomy • PT resulted in no significant difference • Recalcitrant cases - arthroscopic debridement (intra-articular pathology), denervation • Therapeutic Level I study (Australia)

Elbow Tendinopathies Tendinopathies Reading List

Posterolateral Rotatory Instability of the Elbow in Association with Lateral Epicondylitis Medial Epicondylosis Kalainov et al., JBJS 2005; 87-A: 1120-1125. Epidemiology • Three cases reported - multiple steroid injections Overall prevalence < 1% • ECRB degenerative changes may extend to LCL • • Consider PLRI in recalcitrant tennis elbow • Age range 30-60 years • Stress radiographs, MRI may help in diagnosis • Men and women equally affected • Be prepared to reconstruct LCL in these cases • Medial-sided pathology in 10-20% pts • Case report (Northwestern Univ, Rush Univ) • Occupation-related, military population Tendinopathies Reading List Elbow Tendinopathies Clinical Presentation Pathoanatomy • Occupational - repetitive forceful grasping, vibration exposure • MOI - repetitive eccentric loading CFO • Athletics - overhead throwing, golf, tennis • Pronator teres most commonly involved • Late cocking or early acceleration phase • Angiofibroblastic hyperplasia, fibrosis, calcification • Insidious onset common, trauma to CFO • PE - tenderness 5-10 mm anterodistal to ME. Pain, weakness on resisted VF, pronation.

Elbow Tendinopathies Elbow Tendinopathies

Differential Diagnosis Additional Diagnostics • Ulnar neuritis, subluxation • Radiographs - usually normal, but • Cervical radiculopathy up to 25% show medial calcification Elbow MCL insufficiency • Ultrasound - focal tendon lesion, • but operator-dependent Elbow trauma • • MRI / MRA - gold standard when • Other elbow tendinopathy ruling out concomitant pathology

Elbow Tendinopathies Elbow Tendinopathies • Activity modification • Rest from throwing, golfing • NSAIDs Nonoperative • Counterforce strap, taping • JSES 2015 - Level IV Rx - Univ Massachusetts Treatment • Short-term splinting • 60 pts failed 3-6 months nonoperative Rx • ASTYM, but not ESWT • Exam - pronation weakness at 90° key finding • Steroid injection, trephination • Debridement CFO tendinosis, repair w/anchor • Flexor-pronator stretching • Outcome - pain and function (MEPS) improved • Concentric strengthening Eccentric strengthening Elbow Tendinopathies • Elbow Tendinopathies Read File

Operative Treatment of Medial Epicondylitis: The Results of Operative Treatment Influence of Ulnar Neuropathy of Medial Epicondylitis Gabel & Morrey, JBJS 1995; 77A: 645-50. Kurvers, JBJS 1995; 77A: 1374-79 • Review 36 elbows, 26 pts, 16 w/ulnar neuropathy • 40 consecutive elbows in 38 pts, mean age 42 yrs • Pain on resisted forearm pronation in 28 of 36 • Concomitant ulnar neuritis in 24 elbows • Debrided CFO, decompressed or transposed nerve • Rx w/debridement CFO, ulnar nerve decompression • Good or excellent - 24 of 25 w/o or w/mild ulnar in 17 of 24 elbows neuropathy, but only 2 of 5 w/mod or severe sxs • 11 of 16 w/o ulnar neuritis were symptom-free, but • Ulnar neuropathy negative prognostic factor only 3 of 24 w/ulnar neuritis were asymptomatic

Elbow Tendinopathies Read File Elbow Tendinopathies Read File